Treatment of Hypertension

Jai Radhakrishnan, M.D.Division of Nephrology

Based on the Seventh Report of the

Joint National Committee on

Prevention, Detection ,Evaluation and Treatment

of High Blood Pressure (JNC-7)

Objectives Define hypertension Principles of treatment Special groups

S lid e S o u r c eH y p e r t e n s io n O n l in e

w w w . h y p e r te n s io n o n lin e . o r g

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2 0

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6 0

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P r e v a le n c e o f H y p e r te n s io n in th e U SP r e v a le n c e o f H y p e r te n s io n in th e U SPerc

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1 8 - 2 9

B a s e d o n N H A N E S I I I ( p h a s e 1 a n d 2 )H y p e r te n s io n d e fi n e d a s b lo o d p r e s s u r e 1 4 0 / 9 0 m m H g o r t r e a tm e n t

3 0 - 3 9 4 0 - 4 9 5 0 - 5 9 6 0 - 6 9 7 0 - 7 9 8 0 +A g e

3 %9 %

1 8 %

3 8 %

5 1 %

6 6 %7 2 %

J N C - V I . A r c h I n te r n M e d . 1 9 9 7 ;1 5 7 :2 4 1 3 - 2 4 4 6 . w w w .h y p e r te n s io n o n lin e .o r g

Blood Pressure Classification

BP CLASSIFICATION SBP DBP

Normal <120 and <80

Prehypertension 120-139 or 80-89

Stage 1 HTN 140-159 or 90-99

Stage 2 HTN >160 >100

Why Treat Hypertension ? To decrease:

Cerebrovascular Accidents 35-40% Coronary events 20-25% Heart failure 50% Progression of renal disease Progression to severe hypertension All cause mortality

Awareness, Treatment and Control of Blood Pressure 1976-2000 (NHANES)

01020304050607080

1976-1980 1988-1991 1991-1994 1999-2000

AwarenessTreatmentControl

Factors to Consider in Treating Hypertension

Repeat readings r/o secondary causes Estimate CV risk status Co-morbid conditions Lifestyle changes Drugs

“Secondary” Hypertension Difficult to control Sudden onset of HTN Well controlled-> difficult to

control Severe hypertension History/physical/labs

Initial Workup of Secondary HTN Renal parenchymal disease

UA, spot urine protein/creatinine, serum creatinine, USG.

Renovascular Captopril scan

Coarctation Lower Extremity BP

Primary aldosteronism Serum and urinary K Plasma renin and aldosterone ratio

Pheochromocytoma Spot urine for metanephrine/creatinine

Laboratory Tests in Uncomplicated HTN ECG Urine analysis Blood glucose, hematocrit Basic metabolic panel Lipid profile after 9-12 hour fast Urine microalbumin

Estimate Risk Status Hypertension Smoking Obesity (BMI > 30kg/m2) Dyslipidemia Diabetes Microalbuminuria or GFR <60ml/min Age > 55 (men), 65 (women) Family history of CVD

(Men< 55, Women <65)

Metabolic Syndrome

Target Organ Damage Heart Disease

CAD (Angina, myocardial infarction, coronary revascularization

Left Ventricular Hypertrophy Heart Failure

Stroke/TIA Chronic kidney disease Peripheral arterial disease Retinopathy

Goals of Therapy BP <140/90 mmHg

BP <130/80 mmHg in patients with diabetes or chronic kidney disease.

Achieve SBP goal especially in persons >50 years of age.

Lifestyle ModificationModification Approximate SBP

reduction(range)Weight reduction 5–20 mmHg/10 kg weight loss

Adopt DASH eating plan

8–14 mmHg

Dietary sodium reduction

2–8 mmHg

Physical activity 4–9 mmHg

Moderation of alcohol consumption

2–4 mmHg

Drugs for Hypertension Diuretics

Thiazide Loop diuretics Aldosterone antagonists K-sparing

Adrenergic inhibitors Peripheral agents Central (α-agonists) alpha -blockers* beta-blockers Alpha+beta-blockers

Direct Vasodilators *

Calcium channel blockers

Dihydropyridine Non dihydropyridine

ACE-inhibitors

Angiotensin-II blockers

* Usually not monotherapy

Algorithm for Treatment of Hypertension

Not at Goal Blood Pressure (<140/90 mmHg) (<130/80 mmHg for those with diabetes or chronic kidney disease)

Initial Drug Choices

Drug(s) for the compelling indications

Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB)

as needed.

With Compelling Indications

Lifestyle Modifications

Stage 2 Hypertension (SBP >160 or DBP >100 mmHg)

2-drug combination for most (usually thiazide-type diuretic and

ACEI, or ARB, or BB, or CCB)

Stage 1 Hypertension(SBP 140–159 or DBP 90–99

mmHg) Thiazide-type diuretics for most.

May consider ACEI, ARB, BB, CCB,

or combination.

Without Compelling Indications

Not at Goal Blood Pressure

Optimize dosages or add additional drugs until goal blood pressure is achieved.

Consider consultation with hypertension specialist.

Classification and Management of BP for adults

*Treatment determined by highest BP category.†Initial combined therapy should be used cautiously in those at risk for orthostatic hypotension.‡Treat patients with chronic kidney disease or diabetes to BP goal of <130/80 mmHg.

BP Class SBP DBP Lifestyle

Initial drug therapy Without compelling

indication Compelling indications

Normal <120 <80 Encourage

None None

Pre-hypertension

120–139

or 80–89

Yes No antihypertensive drug indicated.

Drug(s)

Stage 1 Hypertension

140–159

or 90–99

Yes Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination.

Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed.

Stage 2 Hypertension

>160 or >100

Yes Two-drug combination (usually thiazide and ACEI or ARB or BB or CCB).

Special Considerations

Compelling IndicationsSpecial populations

HTN with COPD and MIA 55 year old patient with COPD and HTN

(controlled with nifedipine) is admitted with severe chest pain x24 hrs.

BP is 170/100 and she has a soft S3 gallop.

ECG shows an anterior wall MI.

She is not a candidate for thrombolysis. ECHO shows an ejection fraction of 35%.

How will you manage her hypertension?

Compelling Indications for Certain Drug Classes

HTN with CAD Beta blockers: cardioprotective

(reinfarction, arrhythmias and sudden death)

ACE inhibitors: MI with systolic dysfunction- heart failure and mortality improved

Renal Insufficiency A 30 year old patient with IDDM is referred

with difficult-to-control HTN on diltiazem and clonidine.

Exam reveals BP=190/100 and 3+ edema.

Labs: Creatinine = 2.2 mg/dLSerum K = 5.1 meq/L24 hour protein = 5 g

Hypertension with Renal Insufficiency Goal BP <130/80 ACE-inhibitors/angiotensin receptor

blockers should be used if no contraindications

Most patients have volume overload: Diuretics should be included in the regimen. Thiazides ineffective if S Creat>2.5

A 40 year old previously healthy male is brought to the E.R. with 3 days of progressive shortness of breath and has experienced blurred vision in both eyes.

Physical exam:

Blood pressure 230/140. Lethargic. Eye exam: PapilledemaChest: Bibasilar cracklesCardiac: S1S2S4Neuro: Bilateral upgoing plantars:Extr: 2+ edema

Labs: K=3.4, BUN=35, Creatinine: 2.2

CXR: Pulmonary edema

Urine: 10-15 red cells, 2+ albumin.

Hypertensive Urgencies and Emergencies HYPERTENSIVE EMERGENCIES

Require immediate blood pressure reduction (not necessarily to normal range) to prevent or limit target organ damage.

HYPERTENSIVE URGENCIES Require reduction of blood pressure within a few hours

Emergencies & Urgencies

HYPERTENSIVE EMERGENCIES

Require immediate blood pressure reduction (not necessarily to normal range) to prevent or limit target organ damage.

HYPERTENSIVE URGENCIES

Require reduction of blood pressure within a few hours

Parenteral Drugs For Treatment of Hypertensive Emergencies

VASODILATORS Nitroprusside Fenoldopam Nitroglycerine Enalaprilat Nicardipine Hydralazine

ADRENERGIC INHIBITORS

Labetalol Esmolol Phentolamine

Pregnancy and HypertensionA 24 year old primiparous woman is seen in

the obstetric clinic at 30 weeks gestation.

BP: 160/100, 2 + pedal edemaOtherwise unremarkable physical exam.Urine shows 1000 mg of protein. Other labs: N

After 2 days of bed rest BP remains 160-170/100

Drug Therapy of the Hypertensive Pregnant Patient

Methyldopa: Drug of choice. Beta blockers (not early pregnancy). Hydralazine is the parenteral drug of

choice.

Most agents if used prior to pregnancy may be continued (except ACE-I OR A-II BLOCKERS)

Resistant Hypertension Improper BP measurement Excess sodium intake Inadequate diuretic therapy Medication

• Inadequate doses• Drug actions and interactions (e.g., nonsteroidal anti-inflammatory

drugs (NSAIDs), illicit drugs, sympathomimetics, oral contraceptives)• Over-the-counter (OTC) drugs and herbal supplements

Excess alcohol intake Identifiable causes of HTN

Conclusions The initial approach to hypertension should start with ruling out secondary

causes, detecting and treating other cardiovascular risk factors, and looking for target organ damage.

Treatment should always include lifestyle changes. Medication use should be guided by the severity of HTN and the

presence of “compelling” indications. Thiazide-type diuretics should be initial drug therapy for most, either

alone or combined with other drug classes. Most patients will require two or more antihypertensive drugs

Conclusions HTN is a risk factor for mortality

and cardiovascular and renal disease

HTN is common but not controlled. Target BP 140/90 (130/80 in DM,

CKD) Remember Compelling Indications

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